Prediction of Cross-Clamp-Induced Cerebral Ischemia During Carotid Endarterectomy Using Arterial Blood Flow Assessment.

BACKGROUND: Cross-clamping during carotid endarterectomy (CEA) is associated with the risk of cerebral ischemia. Various studies have evaluated different criteria for detecting cerebral ischemia, but difficulties arise when ischemic changes appear after the carotid artery is cross-clamped and incised. Here, we explored a parameter that can predict cerebral ischemia prior to cross-clamping during CEA using a blood-flow meter. METHODS: The carotid arterial blood flow was measured directly (direct ABF) in the common carotid artery prior to cross-clamping. The anatomical information in preoperative magnetic resonance imaging, cerebral blood flow in xenon-enhanced computed tomography, and carotid peak systolic flow velocity by carotid echo from the skin surface were also evaluated. A decrease in the short-latency somatosensory evoked potentials (SSEP) during cross-clamping to insert a shunt was assessed, and a decrease in amplitude of ≥ 50% was considered an indicator for cerebral ischemia. Surgery was performed under general anesthesia, and a shunt was inserted in all cases. RESULTS: Of 156 CEA patients between April 2013 and March 2020, 30 had decreased SSEP during cross-clamping. The baseline characteristics and intra- and postoperative findings were not significantly different between patients with and without a decrease in SSEP. Among the evaluated parameters, only the direct-ABF ratio (ABF-internal carotid artery/ABF-common carotid artery) differed significantly between the 2 groups (P = 0.011). The direct-ABF ratio ≤ 0.58 was predictive of cerebral ischemia during CEA. CONCLUSIONS: Direct-ABF measurement with an ultrasonic blood-flow meter can be useful for predicting cerebral ischemia prior to carotid artery cross-clamping during CEA.

Editor's Choice - Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials.

OBJECTIVE: Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed. METHODS: The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation. RESULTS: A total of 4 754 patients from recent trials and 1 227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (χ2 = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019). CONCLUSION: Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.

Systematic review of preoperative carotid duplex ultrasound compared with computed tomography carotid angiography for carotid endarterectomy.

INTRODUCTION: We reviewed the literature for preoperative computed tomography carotid angiography and/or carotid duplex to determine their respective sensitivity and specificity in assessing the degree of carotid stenosis. We aimed to identify whether one imaging modality can accurately identify critical stenosis in patients presenting with transient ischaemic attack or symptoms of a cerebrovascular accident requiring carotid endarterectomy. METHODS: Systematic search of MEDLINE, Embase, Cochrane database of systematic reviews, all Evidence-Based Medicine Reviews (Cochrane Database of Systematic Reviews, ACP Journal club, Database of Abstracts of Reviews of Effects, Cochrane Clinical Answers, Cochrane Controlled Trials Register, Cochrane Methodology Register, Health Technology Assessment and NHS Economic Evaluation Database) for primary studies relating to computed tomography carotid angiography (CTA) and/or carotid duplex ultrasound (CDU). Studies included were published between 1990 and 2018 and focused on practice in the UK, Europe and North America. RESULTS: The sensitivity and specificity of CTA and CDU are comparable. CDU is safe and readily available in the clinical environment hence its use in the initial preoperative assessment of carotid stenosis. CDU is an adequate imaging modality for determining stenosis greater than 70%; sensitivity and specificity are improved when the criteria for determining greater than 70% stenosis are adjusted. Vascular laboratories opting to use duplex as their sole imaging modality should assess the sensitivity and specificity of their own duplex procedure before altering practice to preoperative single imaging for patients. CONCLUSIONS: The sensitivity and specificity of CTA (90.6% and 93%, respectively) and CDU (92.3% and 89%, respectively) are comparable. Both are dependent on criteria used in vascular laboratories. CDU sensitivity and specificity was improved to 98.7% and 94.1%, respectively, where peak systolic velocity and end diastolic velocity were assessed. Either modality can be used to determine greater than 70% stenosis, although a secondary imaging modality may be required for cases of greater than 50% stenosis.

Risk-Benefit Assessment of Carotid Revascularization.

Severe carotid atherosclerotic disease is responsible for 14% of all strokes, which result in a high rate of morbidity and mortality. In recent years, advances in clinical treatment of cardiovascular diseases have resulted in a significant decrease in mortality due to these causes. To review the main studies on carotid revascularization, evaluating the relationship between risks and benefits of this procedure. The data reviewed show that, for a net benefit, carotid intervention should only be performed in cases of a periprocedural risk of less than 6% in symptomatic patients. The medical therapy significantly reduced the revascularization net benefit ratio for stroke prevention in asymptomatic patients. Real life registries indicate that carotid stenting is associated with a greater periprocedural risk. The operator annual procedure volume and patient age has an important influence in the rate of stroke and death after carotid stenting. Symptomatic patients have a higher incidence of death and stroke after the procedure. Revascularization has the greatest benefit in the first weeks of the event. There is a discrepancy in the scientific literature about carotid revascularization and/or clinical treatment, both in primary and secondary prevention of patients with carotid artery injury. The identification of patients who will really benefit is a dynamic process subject to constant review.

Risk-Benefit Assessment of Carotid Revascularization / Avaliação do Risco-Benefício da Revascularização Carotídea

Abstract Severe carotid atherosclerotic disease is responsible for 14% of all strokes, which result in a high rate of morbidity and mortality. In recent years, advances in clinical treatment of cardiovascular diseases have resulted in a significant decrease in mortality due to these causes. To review the main studies on carotid revascularization, evaluating the relationship between risks and benefits of this procedure. The data reviewed show that, for a net benefit, carotid intervention should only be performed in cases of a periprocedural risk of less than 6% in symptomatic patients. The medical therapy significantly reduced the revascularization net benefit ratio for stroke prevention in asymptomatic patients. Real life registries indicate that carotid stenting is associated with a greater periprocedural risk. The operator annual procedure volume and patient age has an important influence in the rate of stroke and death after carotid stenting. Symptomatic patients have a higher incidence of death and stroke after the procedure. Revascularization has the greatest benefit in the first weeks of the event. There is a discrepancy in the scientific literature about carotid revascularization and/or clinical treatment, both in primary and secondary prevention of patients with carotid artery injury. The identification of patients who will really benefit is a dynamic process subject to constant review.

Resumo A doença aterosclerótica carotídea grave é responsável por 14% de todos os acidentes vasculares cerebrais (AVC), que refletem em uma alta taxa de morbimortalidade. Nos últimos anos, os avanços no tratamento clínico das doenças cardiovasculares geraram um decréscimo importante na mortalidade por estas causas. Revisar principais estudos que dizem respeito à revascularização carotídea avaliando a relação entre risco e beneficio deste procedimento. Os dados encontrados indicam que o procedimento só deve ser realizado se houver um risco periprocedimento menor que 6% em pacientes sintomáticos para que haja beneficio líquido na intervenção carotídea. O tratamento clínico reduziu significativamente o benefício líquido da revascularização na prevenção de AVC em pacientes assintomáticos. Registros que refletem a prática diária demonstram que a angioplastia carotídea esta associada a um risco periprocedimento mais elevado. O volume anual de procedimentos por operador e a idade dos pacientes têm uma importante influência nas taxas de AVC e morte pós angioplastia. Pacientes sintomáticos têm uma maior incidência de AVC e morte após procedimento. A revascularização tem o maior benefício nas primeiras semanas do evento. Existem discrepâncias na literatura científica com relação à revascularização carotídea e/ou tratamento clínico, tanto na prevenção primária quanto secundária de pacientes com lesão carotídea. A identificação do paciente que realmente será beneficiado é um processo dinâmico sujeito a constante revisão.

Outcomes after carotid endarterectomy among elderly dual Medicare-Medicaid-eligible patients.

OBJECTIVE: To determine whether patients who are dual eligible for Medicare and Medicaid benefits have outcomes after carotid endarterectomy (CEA) that are comparable to the outcomes of those eligible for Medicare alone. METHODS: The study cohort included fee-for-service Medicare beneficiaries ≥65 years of age who underwent CEA (ICD-9-CM code 38.12) between 2003 and 2010. Beneficiaries with ≥1 month of Medicaid coverage were considered dual eligible. We fit mixed models to assess the relationship between coverage (dual eligible vs Medicare only) and outcomes over time after adjustment for demographic and clinical characteristics. RESULTS: There were 53,773 dual-eligible and 452,182 Medicare-only beneficiaries hospitalized for CEA. The percentage of dual-eligible patients receiving CEA increased from 10.1% in 2003 to 11.5% in 2010, with no change in geographic distribution across the country. In adjusted analyses, dual-eligible vs Medicare-only beneficiaries had a higher rate of 30-day ischemic stroke or death; higher in-hospital, 30-day, and 1-year all-cause mortality; and higher 30-day all-cause readmission. Relative annual reductions in outcomes from 2003 to 2010 ranged from 2% to 5%, but there was no significant interaction between dual-eligible status and time. CONCLUSIONS: Dual-eligible beneficiaries had worse outcomes than those eligible for Medicare alone. Additional work is necessary to understand the reasons for this difference.

Comparison of Eversion Carotid Endarterectomy and Patch Carotid Endarterectomy: A Retrospective Study of 6 Years of Experience.

BACKGROUND The aim of this study was to compare early and long-term results of eversion carotid endarterectomy (e-CEA) and patch carotid endarterectomy (p-CEA). MATERIAL AND METHODS In a retrospective study, we collected data on 441 patients who underwent CEA (e-CEA=211 vs. p-CEA=230) between October 2009 and October 2015 at our institute. Economic costs, postoperative hospital days, use of shunts and antibiotics, early (30-day) complications, long-term restenosis, and mortality rates were compared between groups during 4 to 76 months of follow-up. RESULTS Patients in the p-CEA group had a significantly higher percentage of antibiotic use (58.3% vs. 27%, respectively; P0.05). Long-term complication, including stroke or heart attack, recurrent stenosis rate, and mortality rate, showed no difference between the 2 groups (all P>0.05). Kaplan-Meier analysis shows that the recurrent stenosis-free and survival rates were not significantly different between the 2 groups (P=0.867, P=0.177, respectively). CONCLUSIONS The adverse event rates of perioperative and long-term follow-up showed no significant difference between the e-CEA and p-CEA groups. Both e-CEA and p-CEA are effective for carotid artery stenosis.

[Severe Carotid Artery Disease;Preoperative Assessment and Perioperative Management].

Cerebrovascular complication is the one of the most dreadful complication after open heart surgery which leads to significant decrease of quality of life even if the patients survived. To decrease these complications, carotid doppler echo as one of the non-invasive carotid screening modalities is effective. Carotid artery stenosis is common in the patients with coronary artery disease, and it is more frequent in the patients with more complexed coronary artery lesions. The more the patients indicated for coronary artery bypass grafting has complexed lesions these days, the more the patients have carotid artery lesions. In case of presence of significant carotid artery stenosis with symptom, carotid artery intervention, either carotid endarterectomy or carotid artery stenting, should be considered by multidisciplinary team. The carotid artery stenosis could cause cerebral infarction by 2 major mechanisms, which are emboli, and low perfusion pressure. In open heart surgery, it is very important to avoid these occasions. Although It is still controversial whether off-pump coronary artery bypass grafting is superior to conventional on-pump coronary artery bypass grafting in randomized trial, it is necessary in common to avoid atheromatous emboli from aorta and to avoid low perfusion pressure by all means.

Modified Eversion Carotid Endarterectomy (mECEA): Analysis of Clinical and Financial Outcomes.

BACKGROUND: Several carotid endarterectomy techniques have been described, including conventional carotid endarterectomy (CCEA) performed with patch repair and eversion carotid endarterectomy (ECEA) performed with transection of the internal carotid artery. We describe our simplified technique of modified eversion carotid endarterectomy (mECEA) with longitudinal arteriotomy limited to the carotid bulb, without transection of the internal carotid artery and present our analysis of its safety, efficacy, and cost effectiveness. METHODS: A retrospective review of all carotid endarterectomies performed by 3 vascular surgeons over a 3-year period was completed. About 197 mECEA were performed during the study period. Follow-up data were obtained on 77.7% of patients. A comparison was made with the contemporary literature with respect to outcomes for both CCEA and ECEA. RESULTS: Between January 2012 and December 2014, a total of 197 mECEA were performed. The perioperative stroke and death rates for those undergoing mECEA was 0.5% and 0.5%, respectively. Late stroke and death rates were 3.0% and 5.1%, respectively. Perioperative rate of myocardial infarction was 1.0%. Early restenosis rates of >70% occurred in 1.4%, whereas late restenosis of >70% occurred in 2.7%. Mean operating time for those undergoing mECEA was 57.9 min. Average costs savings for mECEA compared to CCEA were $5,835. CONCLUSIONS: This simplified technique has comparable outcomes to those described in the contemporary literature for both CCEA and ECEA with respect to postoperative neurologic events as well as restenosis rates. In our institution, the short mean operative times with mECEA has led to reduced resource utilization.

ASSESSMENT OF CEREBRAL PERFUSION IN PATIENTS WITH HEMODYNAMIC ISCHEMIC STROKE UNDERGOING RECONSTRUCTIVE BRACHIOCEPHALIC ARTERY INTERVENTIONS.

The paper deals with the assessment of cerebral perfusion in patients in the acute period of acute cerebrovascular accident before and after revascularization surgery. It gives a clinical example of using contrast-free perfusion magnetic resonance imaging (MRI) in a patient with hemodynamic ischemic stroke. The use of this technique made it possible to determine indications for early carotid endarterectomy for the contralateral internal carotid artery and to evaluate positive postoperative changes in cerebral perfusion and the patient's neurological status. The authors analyzed the current literature on this problem with a particular emphasis on the possibilities of using dynamic susceptibility contrast-enhanced and arterial spin-labeling contrast-free perfusion MRI in this category of patients. Carotid endarterectomy in the acute period of acute cerebrovascular accident can improve cerebral hemodynamics and the patient's neurological status and prevent recurrent cerebral circulatory disorders. Indications for this surgery should be determined by taking into consideration the results of perfusion MRI techniques (single-photon computed tomography contrastenhanced and contrast-free perfusion MRI).

Patient and observer scar assessment scores favour the late appearance of a transverse cervical incision over a vertical incision in patients undergoing carotid endarterectomy for stroke risk reduction.

BACKGROUND: Carotid endarterectomy (CEA) is a very common operation, but there is no agreement on the appropriate orientation of the surgical incision. METHODS: We retrospectively reviewed the charts of patients who had undergone CEA between Jul. 1, 2010, and Dec. 31, 2013. We contacted patients identified in the review to solicit participation in a clinical follow-up examination, during which the esthetic outcome of the scar was evaluated using the Patient and Observer Scar Assessment Scale (POSAS). RESULTS: During the study period 237 CEAs were performed. Nine patients refused the use of their personal health information in this study. There were no significant differences in the neurologic outcomes of patients based on the incision orientation (perioperative stroke and death 1.4% with transverse incision v. 0% with a vertical incision, p = 0.44). Fifty-two patients presented for follow-up examination. Thirty-three had a transverse incision and 19 had a vertical incision. Results of the POSAS significantly favoured the transverse incision (p = 0.03). Vertical incisions were more often associated with persistent, mild marginal mandibular nerve dysfunction (p = 0.04). CONCLUSION: Carotid endarterectomy performed through a transverse skin incision compared with a vertically oriented skin incision is associated with improved esthetic outcome, as measured by the POSAS, without an observed statistically significant difference in the risk of perioperative stroke or death between the 2 techniques.

CONTEXTE: L'endartériectomie de la carotide est une intervention chirurgicale très courante. Toutefois, il n'existe aucun consensus sur l'orientation de l'incision. MÉTHODES: Nous avons analysé rétrospectivement les dossiers de patients ayant subi une endartériectomie de la carotide entre le 1er juillet 2010 et le 31 décembre 2013. Nous avions communiqué au préalable avec les patients concernés pour solliciter leur participation à un examen de suivi clinique au cours duquel le résultat esthétique de leur cicatrice serait évalué au moyen de l'échelle d'évaluation des cicatrices par les patients et les observateurs (POSAS). RÉSULTATS: Au cours de la période visée, 237 endartériectomies de la carotide ont été pratiquées. Neuf patients ont refusé qu'on utilise leurs renseignements médicaux personnels dans le cadre de l'étude. Aucune différence significative n'a été observée quant aux capacités neurologiques des patients selon l'orientation de leur incision chirurgicale (décès et accident vasculaire cérébral périopératoires : 1,4 % avec incision transversale contre 0 % avec incision verticale, p = 0,44). Au total, 52 patients se sont présentés pour un examen de suivi : 33 avaient eu une incision transversale et 19, une incision verticale. Les résultats à la POSAS étaient nettement meilleurs pour les incisions transversales (p = 0,03). Les incisions verticales étaient plus souvent associées à un dysfonctionnement léger, mais persistant de la branche marginale de la mandibule du nerf facial (p = 0,04). CONCLUSION: Notre étude indique que d'après la POSAS, l'endartériectomie de la carotide est associée à un meilleur résultat esthétique lorsqu'elle est pratiquée au moyen d'une incision cutanée transversale qu'au moyen d'une incision verticale. Par ailleurs, aucune différence statistiquement significative n'a été observée quant aux risques de décès et d'accident vasculaire cérébral périopératoires associés à l'une ou l'autre de ces 2 techniques.

Simultaneous carotid artery stenting and heart surgery: expanded experience of hybrid surgical procedures.

BACKGROUND: The aim of this study was to evaluate 10-year results of same-day hybrid revascularization of concomitant carotid artery disease by stenting (CAS) and coronary artery disease by coronary artery bypass grafting (CABG), later also applied to patients requiring CAS and other than coronary open heart cardiac surgery. METHODS: One hundred thirty-two consecutive patients (70 ± 8 years, 102 men) underwent same-day CAS and CABG (group 1, n = 97) or other cardiac surgical procedures (aortic ± mitral valve surgery ± ascending aorta replacement ± CABG; group 2, n = 35). In both groups aspirin (100 mg daily) was started 2 days before CAS and permanently continued; clopidogrel, 300 mg initially followed by 75 mg daily, was started 6 hours after surgery and discontinued 1 month later. In group 2, when required, warfarin was started and aspirin discontinued on the second postoperative day. Mean follow-up was 53 ± 24 months. RESULTS: Overall in-hospital mortality was 3.8% (2.1% in group 1 versus 8.6% in group 2; p = 0.02; 0% for noncoronary isolated procedures, 20% for complex cases), perioperative myocardial infarction was 0%, and stroke was 0.75% (0% in group 1 versus 2.86% in group 2; p = 0.26). Late survival was 81% ± 10% (92% ± 3.2% in group 1 versus 80% ± 11% in group 2; p = 0.45), and overall freedom from neurologic events was 84% ± 6%. CONCLUSIONS: Same-day hybrid approach appeared safe in terms of early and long-term results not only for CAS and isolated CABG but also for CAS and noncoronary isolated procedures. In complex cases, the rate of stroke and myocardial infarction seemed low; in-hospital mortality, as expected, was higher. Long-term survival appeared similarly satisfactory, thus confirming the hybrid approach as a valid therapeutic option for all patients with significant internal carotid artery stenosis associated with coronary and other cardiac lesions, at least for noncomplex cases.

Carotid endarterectomy­safe and effective in a neurosurgeon's hands: a 25-year single-surgeon experience.

OBJECTIVE: Carotid endarterectomy (CEA) is a procedure performed by both vascular surgeons and neurosurgeons in the UK. We present a single neurosurgeon's experience of 728 CEAs over 25 years, performed under both general and local anesthesia, and discuss the results in this context. Our objective was to report on the efficacy of CEA in the hands of a neurosurgeon. METHODS: Prospective outcome data were collected for all patients who underwent CEA performed by the senior author (A.D.M.) from 1987 to 2011. Data evaluated included patient age, sex, surgical indication, preoperative characteristics, diagnostic modalities used, shunt usage, operative time, any neurological deterioration during or after surgery, and early postoperative problems. Outcome measures used were 30-day death and 30-day disabling stroke. The results were tabulated and analyzed using JMP 8.0.2 (SAS Inc., Cary, NC). RESULTS: The 30-day death rate was 0.8% and the 30-day disabling stroke rate was 1.7% in our series. The mean operative time was 135 minutes (±38.1), and the mean clamp time was 28.4 minutes (±8.5). In the subset of patients who had the operation performed under local anesthesia (n = 616), the disabling stroke rate was 1.6% and the death rate was 0.6%. In the subset of asymptomatic patients (n = 194), the 30-day death and 30-day disabling stroke rates were each 1%. Postoperative complications were uncommon. CONCLUSIONS: According to our data, CEA under local anesthesia is safe procedure in the hands of a neurosurgeon and would be recommended according to the clinical presentation and local guidelines.

Stenting versus endarterectomy and the impact of ultra-early revascularization for emergent admissions of carotid artery stenosis.

BACKGROUND: The factors influencing outcomes after emergent admission for symptomatic carotid artery stenosis treated with revascularization by endarterectomy or stenting are yet to be fully elucidated. METHODS: We analyzed revascularization of carotid artery stenosis for patients admitted emergently using the Nationwide Inpatient Sample (2008-2011). Admission characteristics, economic measures, in-hospital mortality, and iatrogenic stroke were compared between (1) endarterectomy and stenting, (2) patients with and without cerebral infarction, and (3) ultra-early (within 48 hours of admission) and deferred (up to 2 weeks) intervention. RESULTS: 72,797 admissions meeting our inclusion criteria were identified. Factors associated with ultra-early revascularization were male patients, low comorbidity burden, stenosis without infarction, and stenting. Ultra-early intervention significantly decreased cost and length of stay, and stenting for patients without infarction decreased length of stay but increased cost. Patients without infarction treated within 48 hours had significantly lower mortality and iatrogenic stroke rate. Patients with infarction receiving ultra-early revascularization had increased odds of mortality and iatrogenic stroke in comparison with the deferred group. Patients with infarction receiving stenting experienced increased odds of mortality in comparison with those receiving endarterectomy, but there was no significant difference in iatrogenic stroke rate. Recombinant tissue plasminogen activator (rtPA) administration on the day of revascularization greatly increased the odds of iatrogenic stroke and mortality. CONCLUSIONS: Larger prospectively randomized trials evaluating the optimum timing of revascularization after emergent admission of carotid artery stenosis seem warranted.

Comparison of carotid artery endarterectomy and carotid artery stenting in patients with atherosclerotic carotid stenosis.

BACKGROUND: The choice of carotid artery endarterectomy (CEA) or carotid artery stenting (CAS), as surgical and interventional treatment of atherosclerotic carotid stenosis, respectively, has been controversial in decades, especially for asymptomatic patients with carotid stenosis. Age and the diameter of impaired carotid artery might be 2 important factors to decide whether CEA or CAS should be performed. Besides, contrast-enhanced ultrasound (CEUS) has been confirmed as an effective method to predict the risk of stroke by classifying the carotid plaque into 4 grades. The role of CEUS in the choice of CEA or CAS still remains unclear. METHODS: A retrospective analysis of 38 patients who underwent CEA with primary closure and 36 patients who underwent CAS in our hospital from October 2008 to January 2013 is conducted. Preoperative CEUS was performed to all patients, and data were collected and analyzed. All CEAs were performed with transverse incision. RESULTS: The hospital stay was longer for the endarterectomy group than the stenting group (15.39 versus 10.91 d, P < 0.001), with an approximately two-third reduction of hospital costs (¥23686.21 versus ¥60855.34, P < 0.001). The overall incidence of perioperative complications in the endarterectomy group was 7.9%, with no statistically significant difference in the group with internal carotid artery greater than or equal to 5 mm and in the group with internal carotid artery less than 5 mm (9.1% versus 6.3%, P = 0.75). No restenosis occurred in either of the subgroups during the follow-up. In patients older than 70 years, the perioperative complications were 0% in CEA and 10.53% in CAS (P = 0.42); the long-term restenosis was 0% in CEA and 5.26% in CAS (P = 0.67). In patients younger than 70 years, the perioperative complications were 11.5% in CEA and 23.53% in CAS (P = 0.31); the long-term restenosis was 0% in CEA and 0% in CAS (P > 0.01). For patients with grade 4 plaque in CEUS, the incidence of adverse events in the CAS group was significantly higher than that in the CEA group (7.14% versus 55.56%, P < 0.05). CONCLUSIONS: There were no significant differences in perioperative complications or restenosis rate between the CAS group and the CEA group in this study. Neither the diameter of impaired carotid artery or age could be considered as an indication of applying CEA or CAS. However, CEUS might be used as a perioperative assessment method to decide whether CEA or CAS should be performed to different patients. The higher the grade of plaque enhancement, the higher the risk of adverse events and restenosis for CAS might occur.

[Comparative assessment of immediate outcomes of surgical treatment of patients with coronary artery disease and lesion of the brachiocephalic arteries].

From 2000 to 2011, a total of 52 patients with combined atherosclerotic lesions of the coronary and brachiocephalic arteries were subjected to a single-stage operation. Depending on the type of operative intervention, all patients were subdivided into two groups: Group One comprising 13 patients who underwent coronary artery bypass grafting (CABG) in a combination with simultaneous stenting of the internal carotid artery, and Group Two consisting of 39 patients subjected to CABG with simultaneous carotid endarterectomy. Assessing the intraoperative parameters revealed that in Group One patients the average duration of operations was significantly lower (179.6±6.4 minutes versus 273.2±5.6 minutes in Group Two, p<0.001) and the time of assisted circulation was less than in Group Two, averaging 75.9±4.5 versus 115.2±3.8 minutes, respectively (p<0.001). The duration of pulmonary artificial ventilation in Group One patients was less than in Group Two patients (9.7±2.6 hours versus 25±4.8 hours, respectively, p< 0.01). Also the duration of staying in the critical care unit was shorter in Group One patients than in Group Two patients (21.5±3.3 versus 82.1±8.0 hours, respectively, p<0.001). The overall hospital mortality rate amounted to 12.8% (5 patients), with all deaths having occurred in Group Two. The lethal outcomes were caused by acute myocardial infarction in three cases, one patient died of progressing multiple-organ failure on the background of acute impairment of cerebral circulation and one death was caused by thrombosis of the mesenteric artery with the development of intestinal gangrene and peritonitis. In the structure of hospital complications cardiac insufficiency was prevalent (23.1% and 59.0% for Groups One and Group Two patients, respectively, p<0.05). Analysing the incidence and structure of other postoperative complications revealed no statistically significant differences between the groups. Our study demonstrated that using surgical methods of treatment of patients with haemodynamically significant stenoses of the coronary and brachiocephalic arteries makes it possible to increase the overall survival rate in patients suffering this disease and to decrease the incidence rate of ischaemic impairments of the coronary and cerebral circulation. The hybrid method of treatment on arteries of various vascular basins may be an alternative to carotid endarterectomy and CABG, especially in patients running high surgical risk.

Effects of carotid endarterectomy or stenting on arterial diameters in the circle of Willis.

BACKGROUND: In patients with internal carotid artery (ICA) stenosis, the circle of Willis (CoW) is the primary collateral pathway. We compared luminal diameters in the CoW before and after carotid revascularization and compared the effects of carotid endarterectomy (CEA) and stenting on these diameters. METHODS: At a single center in the International Carotid Stenting Study, 139 patients with symptomatic ICA stenosis of 50% or more were randomized to stenting (n = 81) or CEA (n = 58). The diameters of all segments of the CoW were assessed on computed tomography angiography (CTA), before and 30 days after revascularization. All evaluations were performed blinded to treatment allocation and order of CTA. RESULTS: A .10-mm increase (95% confidence interval [CI], .02-.17; 7%; P = .01) in diameter after revascularization occurred in the ipsilateral precommunicating anterior cerebral artery (A1), whereas both the ipsilateral and contralateral posterior communicating arteries decreased in diameter by .12 mm (95% CI, .04-.21; 14%; P = .01) and .08 mm (95% CI, .00-.17; 10%; P = .05), respectively. The increase in diameter of the A1 was larger after stenting (.15 mm; 95% CI, .07-.24; P = .001) than after CEA (.02 mm; 95% CI, -.11 to .15; P = .79). Only in patients treated with CEA, the diameters of the contralateral A1 and ipsilateral precommunicating posterior cerebral artery were reduced after revascularization. CONCLUSIONS: Carotid revascularization improves anterior collateralization and reduces reliance on posterior collateral pathways via the CoW. Carotid stenting and endarterectomy appear to have different early effects on collateralization.

A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery.

OBJECTIVES: The aim of this study was a comparison of risk-adjusted outcomes of 3 approaches to carotid revascularization in the open heart surgery (OHS) population. BACKGROUND: Without randomized clinical trials, the best approach to managing coexisting severe carotid and coronary disease remains uncertain. Staged carotid endarterectomy (CEA) followed by OHS or combined CEA and OHS are commonly used. A recent alternative is carotid artery stenting (CAS). METHODS: From 1997 to 2009, 350 patients underwent carotid revascularization within 90 days before OHS at a tertiary center: 45 staged CEA-OHS, 195 combined CEA-OHS, and 110 staged CAS-OHS. The primary composite endpoint was all-cause death, stroke, and myocardial infarction (MI). Staged CAS-OHS patients had higher prevalence of previous stroke (p = 0.03) and underwent more complex OHS. Therefore, the propensity score adjusted multiphase hazard function models with modulated renewal to account for staging, and competing risks were used. RESULTS: Using propensity analysis, staged CAS-OHS and combined CEA-OHS had similar early hazard phase composite outcomes, whereas staged CEA-OHS incurred the highest risk driven by interstage MI. Subsequently, staged CAS-OHS patients experienced significantly fewer late hazard phase events compared with both staged CEA-OHS (adjusted hazard ratio: 0.33; 95% confidence interval: 0.15 to 0.77; p = 0.01) and combined CEA-OHS (adjusted hazard ratio: 0.35; 95% confidence interval: 0.18 to 0.70; p = 0.003). CONCLUSIONS: Staged CAS-OHS and combined CEA-OHS are associated with a similar risk of death, stroke, or MI in the short term, with both being better than staged CEA-OHS. However, the outcomes significantly favor staged CAS-OHS after the first year.